Wednesday, May 31, 2006

Murky Thoughts posted a comment recently about an inmate wanting a sex change operation. I figured that was a natural lead-in to a short discussion about inmates' rights to treatment. Correctional folks already know this, but for those of you who are totally new to the field or who don't work in it this may be useful.

The constitutional basis for the right to treatment rests in the 8th Amendment to the Bill of Rights. This is the amendment which prohibits cruel and unusual punishment. When deciding whether or not something is "cruel and unusual" the courts look at the following factors:

Does the punishment involve the wanton infliction of pain or suffering?

Is it arbitrarily applied or excessive to the crime?

Is it shocking to the conscience?

Is it inconsistent with 'evolving standards of decency'?

Failure to provide medical care to a prisoner could lead to an excessive punishment if it leads to an inmate's death, a result clearly not intended by the sentencing judge in most cases. Untreated medical conditions can also obviously cause pain and suffering. The reference to 'evolving standards of decency' is a recognition that society changes over time; punishments that were used in Colonial times would shock people if applied today.

The landmark case which established medical treatment rights was the 1976 case Estelle v. Gamble. (Yes, the idea that inmates have any rights at all is barely 30 years old!) In this case the US Supreme Court declared that "deliberate indifference" to an inmate's serious medical need was cruel and unusual punishment. (In fact, if you sneak up behind a correctional person today and whisper 'deliberate indifference' you might get a startle response.) Later cases defined some examples of deliberate indifference: an officer who walked over the body of an unconscious inmate lying on the floor of the tier, or an inmate who was not taken for a medical evaluation in spite of obvious bone protruding from his broken leg.

The lay public tends to interpret the issue of treatment rights as a mandate to provide a customized HMO for each prisoner. Not so. The point of Gamble was to forbid institutions from denying access to care. If you lock someone up in a facility with no doctor, that inmate is barred from seeking treatment by the fact that he is in state custody. Here's a free society analogy: imagine if the governor called out the National Guard and ordered them to put up a perimeter around every hospital in the state, so that no one could enter. That would be an equivalent situation.

The right to treatment was expanded later in Bowring v. Godwin (551 F.2d 44, sorry can't find text online right now) in 1977 to include treatment for mental disorders. Case law later gave these examples of serious mental health problems: hallucinations or delusions, bizarre or disorganized behavior, and suicide attempts. Depression per se was not consistently considered a "serious" mental health problem by the courts.

Most correctional litigation since these cases have been class action suits against entire systems, filed by advocacy organizations or the Department of Justice to address infrastructure deficits. Individual inmates may file their own 8th Amendment lawsuits (also called '1983' suits, after the statute which allows institutionalized persons to sue state agents) in addition to state tort (injury) claims.

Getting back to the issue of the sex change operation, there has been established case law in various jurisdictions stating that gender dysphoria or transexualism, from a legal standpoint, is not a serious mental disorder. Thus, a sex change operation would not be constitutionally mandated. The thing to know about situations like this though is that a decision in one jurisdiction is not legally binding upon others. This case would have no precedential value for the country as a whole unless it was addressed & decided by the U.S. Supreme Court. Given the current membership of the Supremes, I wouldn't start buying any high heels just yet.

Then again, high heels would just be more cruel and unusual punishment.

(OK, so it's not a short discussion topic.)

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I know we have a number of global readers of this blog. I would be interested in others' (ie non-American) experiences, if any, regarding right-to-treatment litigation on behalf of the mentally ill. I know from casual conversation with some of my foreign colleagues that America is a wierd beast regarding the amount of correctional litigation we do.

I started to comment on Dinah's post, entitled That's Entertainment???, about reality TV shows exploiting folks with mental illness, and my comment turned into this new post. I have come to the following reasoned conclusion. Ahem.

I am quite certain that at some point, soon, there will be a reality therapy show... more likely an internet video log, or vlog. You know, a webcam in your office, for the world to see what happens in therapy. "Bringing The Couch into your living room."

Every Tuesday evening from 7-7:50, for example, "Melissa" can be seen talking with her therapist (live). God forbid if she's late, as the shrink would then look into the cam, telling why he thinks she's acting out because of the interpretation he offered the previous week, and her troubles confronting authority figures... maybe even with video-snippets from prior sessions, driving home the point. I'm sure if you miss a session, or "show", you can download it to your iPod from iTunes, and watch it when *your* patient no-shows, all the while wishing that you could have a successful therapy vlog, like Dr. Pheel has.

Some patients will even develop their own following, like groupies, cheering their successes on, or jeering at the more narcissistic or annoying "clients". I suppose if there are advertising sponsors, then the therapy would be free for the patient, and the therapist would reap some financial benefit. Perhaps Google ads popping up on either side of the screen, at the mere mention of a product or service by the doctor or patient:

Sponsored Links

Toxic Waste WeightCleanse the waste "weight" and lose more pounds and inches.www.puristat.com

"Doc, ever since I started taking the Paxil, I've gained so much weight. And I've been constipated. It's really depressing."

Sponsored Links

Constipation Gone ForeverRead about the #1 natural remedy for constipation. It works!www.DrNatura.com

Netizens would flock to the patients' blogs to see what they are *really* thinking between sessions, leaving comments about how insensitive the shrink is; or how she should let go of the idea that her bitch of a mother will ever care about anyone but herself; or about how she is such a misandrist (or, he, a negative animus); or that her iatrist is using the wrong otropic drug; or that she could become a "clear" if she just joined the org; or maybe even that, for the low price of just $9.99, in four easy installments, that she, too, could have her very own Emotional Support Duck, thus, forever doing away with the perverse dependency on her work-a-day psychiatrist.

It would get people interested in therapy again, like in the 60's, but only more tricked-out and jazzed-up for the plugged-in generation. Who needs insurance? If your problems are interesting enough, or bizarre enough, all you need is a therapy sponsor. If you are willing to try out the latest pharmaceutical, the drug company may even sponsor your reality therapy vlog, though probably with a side contract stating that for a given sum of money you will not divulge any unpleasant reactions you might experience, such as a blue tint to your vision, spontaneous flatulence, or painful erections lasting longer than 4 hours or 10 inches.

Some day soon, this year or next, web-enabled therapeutic voyeurism -- dubbed PsychoTherapy 2.0 -- will become the biggest thing to hit Psychotherapy since Managed Care. Or Prozac.

It took me a while to figure this out, from the headline, Mental health chiefs blast 'dangerous' Big Brother, I somehow thought "Big Brother" referred to one of those altruistic organizations where men adopt fatherless boys to nurture and mentor. Finally, in my Pop-Culture Deprivation state, I figured out that Big Brother is a reality show where they throw a bunch of people into a house together and stick 'em on TV so people can watch them bitch at each other about who left the dishes in the sink. Or so I imagined.

Not this show.

"Sam Brodie, a pre-operative transsexual, is thought to have mental health issues," notes The Daily Mail. "Sam, 18, has already told housemates: "'I'm the most paranoid person ever.' " The article goes on to report, "Sam is among a host of vulnerable contestants put into the house.Shahbaz threatened to kill himself live on television before quitting the show, Lea has tried to commit suicide and has undergone extensive plastic surgery because she was unhappy with her appearance, Nikki has suffered anorexia and Pete has Tourette's Syndrome. "

Since I get paid to listen to such stories, I just can't fathom how anyone else might enjoy watching this for entertainment. Here in America, we'd never stand for such things.

Sunday, May 28, 2006

Credit for the idea behind this post goes to foofoo5, who asked in a comment about the prevalence of antisocial personality disorder in correctional facilities. This table presents the results of various epidemiologic studies done in prisons. All studies were done using the Diagnostic Interview Schedule (DIS) on a randomly chosen sample of general population prisoners. For those who don't work in corrections, this means that all the subjects were convicted and sentenced offenders rather than pretrial detainees (jail inmates).

In the Cote study, 495 Canadian penitentiary inmates were interviewed using the DIS. They found that schizophrenia occurred at rates seven times higher than lifetime prevalence in the general population of Canada. Bipolar disorder had a six-fold higher prevalence and major depression had a two-fold higher lifetime prevalence. Inmates suffering from the severe disorders almost all met the criteria for at least one other severe disorder or ASPD or substance abuse/dependence. There was also strong clustering of ASPD with substance abuse or dependence relative to the major mental disorders.

In the Daniel study the subjects were 100 consecutive American female offenders admitted to prison. Ninety percent of these women received at least one diagnosis. Sixty-seven percent received more than one diagnosis. These rates were compared with the general population of women in St. Louis (ECA study). The lifetime prevalence of schizophrenia was seven times higher than the general population of St. Louis. Bipolar disorder and major depression were both twice as high as general population.

The final study was done on 109 volunteer inmates in the Washington State Reception Center. They found that 88% of these inmates had at least one psychiatric diagnosis.

There have been other studies since then, but this is just what I had on hand. Foo's comment (pardon the first-syllable familiarity) was specifically about antisocial personality. The low rate in the Daniels study is likely attributable to the subject gender---women tend to get diagnosed with borderline personality personality disorder while men tend to get diagnosed with antisocial personality disorder.

In my experience, about a quarter of our inmates get diagnosed with any personality disorder. I'm always surprised by this because it's quite a bit lower than what you see in the literature. What this tells me is that correctional clinicians don't bother diagnosing trees in a forest. In order to get a personality disorder diagnosis the disorder has to be pretty severe.

I checked the blog yesterday was surprised to find three, count 'em, three new posts by Roy! Is he manic, I wondered? Oh, probably not...just unleashing his pent-up blogs which have been festering... I can only speculate. But this brings me to an interesting study I found, one that pertains to Roy's comments on most frequent diagnoses among psychiatric patients. A landmark 1998 study by Sille, et. al. revealed that the most common psychiatric diagnosis among bloggers is, in fact, Bipolar Disorder, accounting for 61.8% of all psychiatric diagnoses (most recent episode being a Mixed State), followed by Obsessive Compulsive Disorder, with compulsive writing being the most common symptom, followed by compulsive email checking. In a follow-up study done by Monke in 2001, it was found in a randomized, placebo-controlled, double blind study that manic bloggers were more likely to report remission of symptoms, a return to euthymia, and a decrease in compulsive blogging, when treated with a combination of Depakote, chocolate and caffeine. Interestingly enough, none of the bloggers studied responded to either Lithium or any of the novel anti-psychotic agents.

Saturday, May 27, 2006

Ritalin patch: I expect to see this a lot in nursing homes. I've seen methylphenidate make a huge positive impact on older depressed folks, and a patch form of administration makes it easier. But, it's another one of those dang off-label issues that's flaring up lately.

4.6% Medicare cuts next year: Will this ever get fixed? Locally, I hear of folks having a hard time finding psychiatrists who will even take Medicare. It used to be one of the easiest to participate with... no multipage treatment plans, etc. But practice costs increase every year, and we cannot make up the difference by seeing more pts (although I hear there have been some "creative" docs who have learned how to squeeze 50 90807s in a 24-hour day... no, thanks).

Top 10 Psychiatrist Diagnoses: Something is wrong with this picture. The #1 dx is 296.2 (single episode major depr). I would expect recurrent episode major dep to be #1. And all of "Anxiety states" is only #3? I don't think so. The data come from Verispan's survey of 162 psychiatrists. GIGO.

Don't flush your fluoxetine: Says to advise your pts on how to dispose of old pills, but does not say what to tell them. I used to tell them to flush them, but now I say to either return to pharmacy. It seems that flushing has led to high drug levels in the water supply.

Vivitrol: I saw an ad for this recently approved i.m. form of naltrexone (it was going to be named Vivitrex, but I guess this was too close to some other name). Even if there is some efficacy data, this drug will go nowhere. Why? $695 per injection! Are folks gonna pay $22/day to be sober? It's cheaper to stay drunk! Cephalon blew it. I can only imagine that the market they are going after is the court-ordered treatment market. If they hit that one, they will have a blockbuster on their hands, because it is worth $22/day to stay out of jail. (The number of ad-blogs for this drug are incredible.)

Friday, May 26, 2006

In June of last year, I set out to discover Scientology, an undertaking that would take nearly nine months. A closed faith that has often been hostile to journalistic inquiry, the church initially offered no help on this story; most of my research was done without its assistance and involved dozens of interviews with both current and former Scientologists, as well as academic researchers who have studied the group. Ultimately, however, the church decided to cooperate and gave me unprecedented access to its officials, social programs and key religious headquarters. What I found was a faith that is at once mainstream and marginal ... It is an insular society -- one that exists, to a large degree, as something of a parallel universe to the secular world, with its own nomenclature and ethical code, and, most daunting to those who break its rules, its own rigorously enforced justice system.

When asked what, if anything, posted by the apostates is true, Mike Rinder, the fifty-year-old director of the Church of Scientology International's legal and public-relations wing, known as the Office of Special Affairs, says bluntly, "It's all bullshit, pretty much."

The most important, and highly anticipated, of the eight "OT levels" is OT III, also known as the Wall of Fire. It is here that Scientologists are told the secrets of the universe, and, some believe, the creation story behind the entire religion. It is knowledge so dangerous, they are told, any Scientologist learning this material before he is ready could die.

On January 17th, 1986, Hubbard suffered a crippling stroke. A week later, he died, in a 1982 Blue Bird motor home on his property. He was seventy-four years old.

Upon Hubbard's death, his ambitious twenty-five-year-old aide, David Miscavige, who would soon succeed him as leader of the church, announced that Scientology's founder had willingly "dropped" his healthy body and moved on to another dimension. In keeping with Hubbard's wishes, his body was cremated within twenty-four hours. There was no autopsy. But the coroner's report described the father of Scientology as in a state of decrepitude: unshaven, with long, thinning whitish-red hair and unkempt fingernails and toenails. In Hubbard's system was the anti-anxiety drug hydroxyzine (Vistaril), which several of his assistants would later attest was only one of many psychiatric and pain medications Hubbard ingested over the years.

Discussion, as some academics like Kent note, isn't encouraged in Scientology, nor in Scientology-oriented schools. It is seen as running counter to the teachings of Scientology, which are absolute. Thus, debate is relegated to those in the world of "Wogs" -- what Scientologists call non-Scientologists. Or, as Hubbard described them, "common, ordinary, run-of-the-mill, garden-variety humanoid[s]."

The Libertyville-Vernon Hills Area High School District 128 board has voted to suspend students for "maintaining or being identified on a blog site (that) depicts illegal or inappropriate behavior."

Is this for real? I don't see how this can be enforced, and it is easy to see how it can be abused. I am publishing this blog under the name "Roy". Say I called myself Roy Johnson. I could get the real Roy J. in a lot of trouble with the school.

Do you think the real Roy Johnson would sign a blog or a comment under his real name? It seems to me that most blogs are de-identified in this manner. And who defines what is "inappropriate"?

Kids have enough to worry about without having to worry about getting suspended for a blog. How about some education or counseling about online risks? This isn't easy, I know. I called the parent of my child's friend to warn him that his daughter has her cell phone number readily available on another friend's MySpace page. He treated me like I was the Volunteer Fire Department calling at dinner time on a Friday night. I even emailed him the link. The number is still there.

Maybe I should have emailed her school principal. Got her suspended. That would teach her not to blog inappropriately. Of course, what would she do at home while suspended? IM and blog with all the other homebound blogging convicts.

Thursday, May 25, 2006

I don't go to APA every year by any means; I last went in NYC two years ago.

So here is my take on it:

It was too cold in Toronto, especially on Monday.

As of Tuesday, there were 17,000 people registered. In NYC, I believe there were 26,000 registered (I always ask). It seemed like there was less of everything, though maybe it's similar to how the playground slide gets smaller as one gets older. Some sessions were still extremely crowded, and I went to hear Glen Gabbard talk-- he was terrific, but it was like hearing a talk on crowded NYC subway with the body parts of assorted strangers being jammed into me. The quality of the sessions varied, but that isn't new.

It seemed there were many more non-members than usual, and what felt like huge numbers of people from other countries around the world. While this is always the case, it was more striking, and a drug rep told me that 40% of attendees were from other countries (by 'other' I mean not Canada or the US). Lots of folks from Turkey and the Netherlands.

Most notably: the toys were not good. The freebie drug company giveaways (pens, squishy brains) were all but absent; apparently the laws in Canada are stricter about such things, though I wondered if part of it was also due to all the fuss in the press here about drug companies influencing docs. The lack of toys meant the Exhibit Halls-- where I often bump into long lost people from my past lives-- were fairly empty.

Fun things: I made it to Steve Sharfstein's Presidential farewell bash and had dinner at Susur-- an event in its own right. Susur does only a tasting menu, probably the most interesting meal I've ever eaten out, definately the most expensive...the food was delicious. We flew into Buffalo and pit stopped enroute for Buffalo Wings and to see Niagra Falls.

Funniest moment: leaving the country, I handed my passport and boarding pass to the Immigration officer. He asked why I was in Canada and Was I a Psychiatrist. When I said I was, he moaned and said, "At least your not as disorganized as the rest of them."

Tuesday, May 23, 2006

Correctional Officer X** was assigned to work in the psychiatric infirmary. He had been there for years and he was good at it. CO ("Correctional Officer") X was build like a sumo wrestler, only bigger. He had a soothing, mellow, story-telling voice like Garrison Keillor. I swear he could have hypnotized a rabid dog with that voice. Whenever any situation came up on the unit that looked like it could have gotten out of control, he was there. If any of my patients got loud during rounds, he'd poke his head in: "You OK in there, doc?" When he moved down the unit it was like watching an ocean swell move toward a tropical beach. But more than his size, his demeanor set the tone for the milieu. He approached patients in a way that made them feel safe.

He was the ideal physician recruiter. Whenever I brought applicants through the unit I'd introduce them to X. "In case you're nervous about working here," I'd tell them. "Don't you worry," X would say. "You come work here, I got your back."

He was a big (pardon the pun) reason why we never needed to use physical restraints.

Saturday, May 20, 2006

Every psychiatrist knows the DSM criteria for major depression: low mood, decreased self-attitude, changes in sleep, appetite, concentration, memory or sex drive, excessive or inappropriate guilt (and how do you judge that in a correctional facility?), anhedonia and suicidal ideation.

I would like to propose one small additional criteria:

Humor latency. Yes, a delayed or absent response to humor. Particularly my humor. Some people would claim that loss of humor falls under the anhedonia category, but I disagree. Anhedonia could mean almost anything: inability to enjoy knitting, exercise (but then almost everyone would meet criteria), coffee (never!) or Japanese existentialist literature. Humor is universal. Granted, some research suggests there may be gender differences in humor. Other research done on twins suggest that environmental factors play a role. (Where can I get in on a research gig that involves showing Far Side cartoons to twins?)

I'll grant the fact that men and women may appreciate different forms of humor. A male colleague of mine used to be prone to practical jokes---of the 'hide the rubber cockroach in the patient charts' kind of humor---and he referred to April Fool's Day as "Amateur Day". He had a problem with my puns. Or rather, he suffered from "humor latency". This is how he explained it: "I used to think I was just too stupid and didn't get your humor. But then I realized I did."

Roy will be holding down the blog this week. ClinkShrink is already in Toronto (she says: "Bring a coat"). I will be going tomorrow, and yes, I will be flying with an Emotional Support Psychiatrist, let's see if I can get her to wear one of those signs around her neck.....

This whole search for terrorist collaborators thing is getting a little ridiculous. Tapping into millions of domestic phone calls (and probably blogs and emails and IMs) in the name of terrorism? That's legal?

So, here's my nightmare scenario. If this is legal, the next step is to force functional MRIs on people to determine what they know (about terrorism, of course). The technology is there. Functional MRI (fMRI) measures minute changes in blood flow in the brain, comparing areas to see which ones have more blood flow, and thus are more active. It seems that one must use specific brain areas to make stuff up. This technology is being used for good purposes (eg, controlling chronic pain), but could certainly be applied to darker motives.

"Would the Court view an involuntary brain scan as a nonintrusive gathering of information rather than a search governed by the Fourth Amendment? Would the Court view brain scans as forcing an involuntary disclosure of thoughts prohibited by the Fifth Amendment's requirement that individuals not be made to testify against their will?"

fMRI is not "invasive" in the classical sense. No needles. No tubes. Sorta like going through an airport scanner, but lying down (you can even keep your shoes on). So what's to stop them from using this technology on Gitmo detainees (or on us)?

The chronic pain link above is interesting, BTW. It makes me wonder if real-time fMRI scanning can be used to learn how to better control obsessive thoughts or auditory hallucinations or anxiety.

Friday, May 19, 2006

There's not a way of talking about this without sounding like either a self-righteous (probably vegetarian) health food proponent, or a child hater. I'm trying to decide which is worse.

If you've ever had a child who has played a sport, you know what "snack parent" is. If not, this is how it works. You're sitting quietly at the first game, minding your own business, hoping your kid isn't the kid who causes the gut-wrenching loss, when suddenly someone passes you a sign-up sheet: Snack Parent. The dates of play are listed and you are told it will be your responsibility to bring all the little players their after-game snacks. You think about your schedule and choose a date you know you will be available. The call-to-duty is a heavy one; missing a child's game (or God-forbid having your child miss a game because YOU have other obligations--simply unheard of) is bad enough, but missing a game where you are the Snack Parent would be unthinkable.

My family eats dinner together, sitting at the table with cloth napkins. This supposedly prevents future psychopathology, at least in the children. We sit down together at what should be a civilized meal and everyone grabs the food in a rapid free-for-all. The point being, I don't want my kids eating snacks right before we sit down to dinner. And if I did, I'd want some control over the snacks; soda and chips just don't feel like wholesome appetizers.

Okay, so yesterday I was Snack Parent. I'd like to bring carrots, but I visualize my children lying on the analyst's couch saying "Everyone else's mom brought Reese's Cups, My mother brought carrots." The cost alone is enough to drive me to the bakery, and the Guilt-- let's not even go there. Neither, however, compare to the punishment that would be meted out by the carrot-bearing child who will never again be able to show his face.

Back to yesterday. First, I'd never signed up (hmmm, must have overlooked the sheet that day) and I'd gotten an e-mail from the coach pointing out that our family was one of only three families shirking Snack Parent responsibilities. I thought I already did Snack Parent, in fact I did it on my kid's birthday and actually brought cupcakes. Oops, right kid, wrong team. I emailed back a Snack Parent-acceptable date and received email confirmation. Okay, our family springtime activity calendar looks like the military plan for invasion of an enemy nation. I knew there would be no time to Get The Snacks, and so, staring at the diagrams of who-goes-where, I ran out days in advance to Target. I lingered in front of the individual packages of bear-shaped graham crackers in 100-calorie packs. This couldn't be too bad. They come in 12 packs, there are 13 girls on the team. I took two and headed to the drink aisle. As fate would have it, on my way I passed an Orthodox Jewish couple which reminded me that two of the girls on the team are Orthodox Jews. Are bear-shaped graham crackers Kosher? I stared at the package, turned it over and upside down, and could find nothing that would indicate they were Kosher. Back to the snack aisle where I settled on Cheez-Its shaped like SpongeBob Square Pants, 160 calories/package. I surrendered and bought them. The juice aisle yielded similar problems, and I purchased little bottles of water. This, I was sure, would work, and maybe she'll get by on twice-a-week psychotherapy. The schedule failed, my other child's game was canceled, requiring that I somehow be in two places at once, and a neighbor had to pinch-hit because I was Snack Parent. So, the story ends and the Blog Post begins when another family also showed up with snacks: a large assortment of candy bars and cans of Dr. Pepper. The bottled water and SpongeBob Cheez-its were left untouched. I'm just hoping we can find a psychoanalyst with side-by-side Mother/Child couches and two-for-the-price-of-one coupons.

According to a recent post on CNN.com, workers would give up their morning coffee to surf the 'Net. What I'd like to know is how these people can be awake enough to find their computers.

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OK, I'll relate this post to psychiatry somehow. Fortunately, I had a link set aside on my browser bar for just such a moment. It's an old post, but a goodie: What De-Institutionalization Means to Jane & Joe Public. This is a post for those of you who struggle to support loved ones with mental illness or wonder what it's like having a mentally ill family member.

Meanwhile, given our recent discussion of the Angry Patient, I thought I'd link to a recent study published in the American Journal of Cardiology. This study suggests that people who "tend to experience negative emotions and to inhibit the expression of these emotions in social interactions" are at increased risk of adverse cardiac events. The study refers to a "Type D" personality, although I'm at a loss to know how they validated their "Type D personality scale". I think this finding is more likely explained by the known relationship between clinical depression and cardiovascular disease.

Thursday, May 18, 2006

I've spent my life searching for meaning. I realize now (see posts below) that I've been looking in the wrong places-- I should have turned my bucket upside down, found a cozy closet, put a clothespin on my nose, and settled in with a good mentally ill prisoner or two.

Okay, enough on the wonders of correctional psychiatry-- and please do forgive my sarcasm-- teasing ClinkShrink is a lot of fun.

So can I ask, why are we the only blog in America that isn't asking why Chris was voted off American Idol??

Wednesday, May 17, 2006

In the January 2002 issue of the AAPL newsletter there was an interview published with a well-respected & experienced forensic psychologist and correctional clinician, Joel Dvoskin. He described correctional work more eloquently than I have ever heard before. When I finished reading this, I kind of wanted to stand up and cheer:

To me the moral thing, the ethical thing, is not to cut and run. It is to maintain one's dignity and professionalism in the face of bad circumstances. It is to understand the difference between reasonable flexibility and selling out. It is speaking with honor and humility (even in court) about how it ought to be, and resisting the understandable temptation to sink into self-righteous and angry denunciations. It is protecting your own hope against all assaults, because hope is the most precious gift you share with your clients."

I think this should be framed and hung on the wall of every correctional psychiatrist's office.

Tuesday, May 16, 2006

I've been in corrections long enough now that my name has become inextricably associated with prisoners. Free society clinicians occasionally call me and the call goes something like this:

"I was supposed to see Joe Blow** and he didn't show up for his appointment. Could you check and see if he's been locked up?"

Or:

"Joe Blow's sister called and said the police picked him up last night. Could you make sure he gets his medicine?"

For all practical purposes, I've become the local lost-and-found for psychiatric patients. That's OK. I like talking to free society clinicians, particularly the part where I tell them: "Yeah, he's already been seen. I saw him the day after he got locked up and his meds have been ordered."

There's always a bit of a silence at the other end of the line, or a general expression of surprise. People are so used to hearing stereotypes about correctional mental health care---universally negative---that they can't believe a system could ever possibly work well.

On my end of this process, I have a wish list.

I wish that clinicians who call me about their patients' medications would actually know the medications that the patient is on. As in, the name, dose and frequency.

I wish the free society medication regimen would make sense. Granted, psychiatry is as much of an art as it is a science so psychopharmacological approaches can vary reasonably between reasonable clinicians, but I see some med combos that don't come close to reasonable. I get patients from free society who come in on subtherapeutic doses of two or three medications from the same medication class, or on meds with no proven efficacy for the diagnosis the patient has been given. And I am responsible for making treatment decisions given this history.

Sometimes I change medications from what a patient was given in free society. I know this is heresy, and it tends to engender suspicion from my patients and/or concern from outside parties, but I do it. I do it when I want to give treatment that is consistent with current practice guidelines and research. I do it when there are known contraindications or potential complications (like addiction) associated with the free society regimen. I do it because sometimes the patient actually may require less--or no--medication once he/she is abstinent from drugs and alcohol. I do it because I am responsible for doing what's best for the patient, even when the patient demands care that is outmoded or even inappropriate.

Sunday, May 14, 2006

In psychotherapy, Mother's Day is a two week long event. People talk about it the week before and the week after. For mothers in intact families, it gets a brief mention-- there was a nice meal or even some flowers. For those who've lost their mothers, however, it is a rough time, a day when grief re-surfaces, when old wounds get spiced.

Saturday, May 13, 2006

Steve's been helping us figure out how to set up Blogger to more clearly indicate who posts what, since there are three psychiatrists who post here. [Sounds like a joke; "So, these three psychiatrists walk into a blog..."]

If I haven't totally broken the template here, you should start to notice that our individual blogs will have some differences in formatting (font, color, stuff like that), which makes it easier to tell when we switch. This post is, in fact, my test to see if it works (should be different font style).

Hopefully, these changes will allow us to stay more grounded, while maintaining a more integrated appearance.

The patient has had a rough time of it, he's a widower who tragically lost his wife, his only child is a disappointment to him, his boss is demanding and unpleasable.

I would listen sympathetically, but the patient won't talk. He stares at the ceiling and says he doesn't know what he should talk about. I make suggestions; they are all wrong. He's already talked about those things, and why don't I remember? Or he doesn't want to talk about them, it won't help. I ask about something I hope will be benign-- weekend activities, how things are with a family member, even a TV show I know he likes, but anything that isn't charged, he's deemed a waste of therapy time. "What's important to talk about?" I ask, trying every angle I can think of. "You're the doctor," He replies. But it's not a matter-of-fact, or even a slightly annoyed, reply--it's a hostile, you're failing me, dig and he knows right where to aim.

When he does talk, it is to rail at me. I'm not helping him, the medications aren't helping him, the side effects suck. He logs my failures: the time I didn't call his meds in fast enough, the time he was certain he'd left a message I didn't return-- it doesn't matter that I tried and couldn't get through. If I make any reference to the future, one he insists won't come, he uses it as an opportunity to angrily tell me how I haven't been where he's been. He stares at my wedding ring and asks how I'd feel if my husband died, if my kid had the problem his kid has? He makes many assumptions that I've never suffered, and certainly, he announces, not the way he has.

The Angry Patient never misses an appointment, in fact, he arrives early, and he sometimes calls between sessions. He comes, he says, because he is hanging on to his last remnant of hope. He's never had a kind word for me, never even an ounce of tenderness to his tone. I've tried to suggest he see someone else (pleeeease...), for at least a consult. Empathy, I've said, is a necessary part of the psychotherapeutic process, and he feels I have none; perhaps he might find it with someone else? Even I'm giving up on him, he's quick to point out, and I'm not surprised-- I knew he'd see my referral as a rejection. He's not telling his story again, not starting over, and I'm as good as the rest of the quacks (he's test driven quite a few). Gee, thanks, I think.

The Angry Patient stares at the ceiling and I glance at the clock. I keep my tone gentle and even. I listen and I try not to say the wrong thing. I remind myself that he's still grieving, and I try to garner some sympathy for his disabling narcissism, his Cluster-B-ness which he wears like a coat of armor.

If the Angry Patient were just angry, that would be fine. Why does he have to be angry at me? Don't answer that; for the moment, I'm just striving for survival.

Friday, May 12, 2006

One day I was standing at the prison gate waiting to be let in. I felt warm moist air puffing gently against the back of my knees. I turned around and there was a German Shepherd. A big German Shepherd. He was looking up at me and sniffing, taking a great interest in something I couldn't see. I asked the officer who was with him, "Does he eat shrinks?"

The officer laughed, but I noticed he never answered my question. That wasn't comforting.

"What's his name?"

"Oh, I can't tell you that. He's a working dog."

"Can I pet him?"

"No ma'am, he's on the job."

Since I couldn't pet him and I didn't know his name, I called him Harley. I saw Harley around periodically after that, as well as other drug detection dogs I got to know fairly well although not on a first name basis. There was the chocolate lab, the older German Shepherd and the yellow retriever who was my favorite. The retriever would prance through the jail like it was the favorite thing in the world for him to do. He was practically grinning the whole time. Mentally I called him Cute Dog.

One day the retriever's handler showed up without him.

"Where's the pup?" I asked.

"Oh, he's out in the truck," the officer said.

"Ha," I said. "Don't worry, by the time you get back he'll have the transmission fixed. That dog is smart."

I haven't seen Cute Pup for a while and I'm a little worried. Drug detection dogs are a key part of institutional security, but they also help out a little with staff morale. They're our version of Pets On Wheels.

Thursday, May 11, 2006

Persuasion is a key element of psychiatric care, even for those who voluntarily seek treatment. Whether it's persuading people to take lithium, to face uncomfortable psychodynamic interpretations or to abstain from drugs and alcohol, psychiatrists often end up in the position of convincing people that it's a good idea to behave in responsible, healthy ways.

Patients have the freedom to choose to accept or reject treatment. It is their choice to live with their symptoms or tolerate medication side effects. This choice only extends so far, however. When a patient's symptoms infringe on the rights or safety of others, persuation may turn to coercion. Initially this pressure to comply with treatment may come from a loved one who has the most immediate contact with the patient or faces the most direct risk. If the patient becomes ill enough to disturb or endanger others, the legal system may intervene to mandate treatment. Civil commitment procedures were formalized in the 1960's and included provisions for hearings, limitations on the length of confinement and requirements for proving dangerousness or disability. More recently, some states have adopted outpatient commitment procedures. For those involved in the criminal justice system, some jurisdictions have specialized mental health parole programs or mental health courts.

Regardless of the specific mandated treatment paradigm, the trigger issue is usually patient's risk of violence. Mental health clinicians should be aware of the most recent, and probably best, research in this area found in the MacArthur Violence Risk Assessment Study. In short, it found that recently discharged civilly committed psychiatric patients without substance abuse problems were no more dangerous than others in their community without mental illness. The strongest risk factor for violence was substance abuse. Clinicians were able to predict violence with some degree of accuracy.

Tuesday, May 09, 2006

Okay, it was his birthday last week and all, but I think Sigmund Freud single-handedly stalled the progress of psychiatry for nearly a century.

Look at some of the thought leaders in psychiatry in the early 2oth century. Kraepelin. Bleuler. Alzheimer. It was around 1905 when it was found that syphilis could cause a type of psychotic illness, called general paresis of the insane. Most "psychiatrists" were actually neurologists then, and the field was decidedly heading in the what's-wrong-with-their-brain direction. Fifty years later, the first antipsychotic drug was introduced. What happened in those first 50 years, and in the 50 years since?

The locus of pathology switched from the brain to the mind, from the individual neuron to the individual person. We were just starting to realize that psychiatric illness could occur through no fault of one's own (okay, maybe unprotected sex, but you see where I'm going), and then Dr. Freud comes along and we start looking at the mother or the father or Uncle Pete as the source.

And the treatment? Lie on a couch and talk. About whatever comes to mind. Four times per week. For seven years.

The result? Worsening of stigma. Marginalization of Psychiatry from Medicine. Diversion of research interest and resources from the cell to the self. The "psychiatric reduction" and non-parity in health insurance coverage. (The "psychiatric reduction" was Medicare's discriminatory practice of requiring outpatients with psychiatric illnesses to pay 50% out-of-pocket, while all other illnesses cost you 20%. This sham is still on the books today, despite bipartisan efforts to end this anachronism.)Tom Cruise.

So now, with the Decade of the Brain a recent memory, we have now entered the Century of the Genome. We are discovering more and more about how the brain cell is put together, which protein does what, and what goes wrong when the blueprint goes awry. About time.

The damage is fading. People are getting more comfortable to talking about having an illness, less worried about folks wondering about the "dirty little secrets" which have tripped them up.

Don't get me wrong. We learned some things in the process about human psychosocial development... about transference... about id. After all, understanding psychiatric illness cannot be boiled down to neurons and receptors any more than diabetes can be boiled down to insulin and sugar. But we have had a long and winding detour. Time to blow out the candles and get this party started.

The patient is an unassuming man in a dark suit. He works in finance and supports a family. Actually, he supports the family quite well-- wife drives an Escalade, family takes nice vacations, he sports a Rolex and puts the kids through expensive schools. His income, he tells me, is quite good, so good in fact that the money is free-flowing, not from his salary, but from what amounts to white-collar crime on the job. Smarter than others, or so he believes, he is certain he won't get caught and talks about how he has the bases covered. He's not much for worrying about the future and his weekends are filled with cocaine-- of course he's not addicted. He comes to treatment, reluctantly at first and then willingly, even eagerly. His temper is volatile, his moods capricious and unpredictable, he and his wife fight constantly. And no, he won't try lithium, though I plug away with the suggestion.

I'm not so sure what he wants; he's my Tony Soprano, without the violence (I hope) or the mob (I also hope). I wonder if he's pulling my leg, telling these stories to create a bigger self for someone. I wish I could see the parking lot from my window; I haven't asked to examine the Rolex but I wouldn't know a real from a fake anyway. I'm not so sure what Tony is working on in treatment anymore either, but he still comes, and still Dr. Melfi treats him. Like Tony, my patient is not interested in changing, he's undisturbed by the illegality of his assorted behaviors, unbelieving that bad consequences might be right around the corner. I sit in his sessions and I wonder if should continue to treat him: he says therapy helps, that he's feeling better. Dr. Melfi plods on; I suppose that for now, I will too.

Monday, May 08, 2006

While studying for the recertification exam I came across some interesting relevant facts and figures. In a 1990 mortality study of Maryland prisoners, male inmates had a 39% lower all-cause death rate than the Maryland general population. Correctional deaths from AIDS and other causes have also dropped significantly over the past twenty years, according to the Bureau of Justice Statistics. Not coincidentally, this decline occurred over the twenty years since the U.S. Supreme Court mandated medical care for prisoners in the landmark Estelle v. Gamble decision. Makes you wonder how much mortality rates could drop in free society if people made their minds up to commit to broader access to health care.

Sunday, May 07, 2006

Face it, even though psychotropics do wonders for many people, as a society-- and even as a profession-- we remain ambivalent about medicating people for what goes on in their mental life. Oh, of course, there are many examples of people where it's not an issue-- we don't medicate one night of insomnia, and we pretty much agree to medicate anyone with severe symptoms who arrive screaming in psychic pain, but on the edges of the symptom spectrum, there is still controversy, there is still hesitance, and there is still stigma. As psychiatrists, we each have our own threshold in the question of when to medicate.

As we go on with Sigmund Freud's birthday weekend, William H. Gass writes about Freud in The Inside Man in Sunday's New York Times Op-Ed section:

Had there been pills and similar potions he might have prescribed them and swallowed the rationale for their use as well. Cocaine, after all, was a chemical solution he used and quite in harmony with psychiatry's present pill pop, hip hop, rub out attitude.

Pill pop, hip hop-- so this is what I do for a living?Mr. Gass goes on to note:

It became fashionable to be neurotic, to be in analysis and to be able to afford it. And we were having such a good time, we scarcely noticed that this therapy-- which took so long and cost so much-- wasn't curing anybody.

Interesting that Mr. Gass manages to disparage both psychoanalysis and psychopharmacology. I won't speculate on what he does advocate for the treatment of mental illness.

Imagine working in a hospital where the patients change rooms every night and your unit gets 350 new admissions every day. Imagine dispensing medication to hundreds of inmates who come to your pharmacy twice a day to pick up their psych meds. I think of medication times (or "pill line" in correctional idiom) as a kind of March of the Penguins for prisoners. When people wonder why inmates don't always get their medications, I can tell you that some inmates decide they just don't want to face the daily migration. Sometimes they don't want to get up out of bed, or they don't want to take the chance of missing commissary or they have a visit scheduled. Maybe they are afraid of being ridiculed by other inmates. Maybe it's raining out and they don't want to cross the recreation yard. Maybe they are afraid of having confrontations with other inmates during the hour-long wait in line. More likely, the medications work so gradually and the effects are so subtle that they think treatment simply "isn't worth the hassle".

When I read about the effort required to persuade patients to take Lithium my first thought was, "That's so true!". But in addition to dealing with medication side effects, I also have to convince them that going down to get the medication is worth it. Fortunately, I have some research on my side. In the early days of lithium research the first research subjects were prisoners with a history of violence. Lithium was found to cut the rate of infractions in half. This is a strong selling point for my patients---"take your medicine because it's a good way to stay out of trouble."

Sigmund Freud was born at 6:30 p.m. on the sixth of May, 1856, at 117 Schlossergass, Freiberg, in Moravia, and died on the twenty third of September, 1939, at 20 Maresfield Gardens, London. That Schlossergasse has since been renamed Freudova ulice in his honor.-- Ernest Jones, the opening to his three volume biography The Life and Works of Sigmund Freud

Friday, May 05, 2006

It was a hard winter. It started even before that, perhaps in October, right before I left to work in Baton Rouge-- one patient had a serious suicide attempt, several were in crisis, even the patients who were fine were having trouble getting out the door at the end of the sessions. "Treatment-Resistant Depression" had become one of my favorite terms, but there were also a few people with mania and psychosis who were having a tough time. So it continued through the winter-- one patient called at least 10 times a day (I finally told her to stop; this improved the quality of my mental health remarkably), another e-mailed, up to 4 times a day, patients called-- or worse, their relatives called-- they cried, sometimes they even sobbed.

I mentioned it to a few colleagues and they all had the same response: My practice, too! One friend told me her emergency phone line usually gets 2 calls a month, now she was getting 3 a day, including calls from a patient on another continent, all while she'd taken on 3 news patients that week and her husband was out-of-town, leaving her with their 2 young children to negotiate. She beat me out for the Most Suffering Psychiatrist award and I brought her chocolate. Something in the air? Yet one more effect of Global Warming?

I felt discouraged, overwhelmed, and I wondered for the first time if I really loved psychiatry as much as I thought. One friend, a bit more seasoned than I, expressed surprise that it took me this long (I've been in practice since 1992), another wrote, "I wonder why I ever thought sitting with troubled people would make for an interesting career." I quoted her often. Was something different about my world, I wondered, or was I just perceiving everything differently-- after all, I am a psychiatrist, I do work with troubled people, at any given time someone out there is in crisis, maybe I was more sensitive, maybe it wasn't Global Warming.

In March, I went to an all-day seminar on Bipolar Disorder. Ross Baldessarini talked about the wonders of lithium. I've used it a fair amount to as an augmenting agent, but more recently, I think I'd forgotten about it, or given in too easily to patient's initial refusals. I started to re-think all my troubled people, ah, I gave more of them lithium. It's definitely helped a few, including one of my more distressed patients who had been refusing it for months before.

Things are quieter now; I'm not sure if it's Springtime, the longer days, the alignment of the moon, or more lithium.

Lithium is a hard sell. To listen to the experts, you just start people on it. I've found it takes at least 3 separate discussions to get someone to try it. In the last weeks, one patient called me in tears insisting I'd made her so much worse just by suggesting she take lithium, another man started shaking and said, "Doc, you're making me really nervous." Lithium has gotten a bad rap over time, and for some reason it's so much easier to get folks to try anti-psychotics. "It's an element, natural, just a salt" has gotten me nowhere. In a few cases, I've resorted to asking patients to take one pill, just one pill, and call me right after they've swallowed it. The first dose is the hardest, or so it seems. I have to promise I'll let them stop if they have side effects (or as I sometimes put it, "intolerable" side effects) and I keep the levels low, sometimes really low.

"You have no new messages." I love the sound of the mechanical lady on my voicemail. Is it just the calm before the Manic storm, I wonder. Maybe, but for the moment, I'll take it.

Wednesday, May 03, 2006

Most psychiatrists don't hear patients talking about their relief at getting arrested. Certainly incarceration isn't discussed in any positive light in the media. In the past week three of my patients expressed relief about their incarceration. It was an admission that their lives had become out of control. In one case, a family member called the police knowing that it would be the only way for the patient to get "cleaned up and get the help I needed". People would argue that if there were enough "treatment-on-demand" substance abuse beds this would obviate the need for arrests, but from direct inmate experience I can tell you that many of my patients would not willingly go to treatment. Whether or not incarceration is a cost-effective intervention is up for the economists to decide. All I can tell you is that this week it was life-saving.

"And now for something completely different..."

One Oregon correctional facility found a way to turn vocational training into e-commerce. Prison Blues sells denim clothing manufactured by prisoners in the Oregon Department of Corrections. The company's theme is "made on the inside, to be worn on the outside". The catalog once featured inmates themselves as models, with their offenses listed along with the clothing information.

Now I don't just write a blog, I read other people's blogs: it's like throwing Time in the fire and watching it burn.

Last night, I said to my husband, "Hon (we've lived in Baltimore for 17 years, I've sunk to calling him "hon"), I think the blog is getting to be a problem." He simply answered, "Yup."

Roy, who somehow supports a family, directed me to Fat Doctor's blog. He assigned me a mission to get her to post our blog-- so far, we're nowhere and it's mostly been Clinkshrink, Roy, and I talking to each other. I found Fat Doctor: a "Famine-resistant doctor, wife, mom, cynic and active daydreamer. Blogging for 15 minutes each morning to better avoid starting my day." A beleaguered soul who suffers from Depression and is now off her Prozac, Fat Doctor won my heart-- I laughed out loud when I should have cried. She has a wonderfully self-effacing, charismatic sense of humor. Strangely, I wanted her blog to be my blog.

Hours after discovering Fat Doctor, I returned to learn she is in the hospital having suffered a stroke, still blogging. Her followers have wished her well, as I do now, though I feel like a bit of an intruder. We'll leave my blog-swapping mission for another day.

No, I'm not talking about a new pill. The rumor mills are stirring about Apple coming out with an Ulta-Mobile PC (UMPC)... a tablet PC in a small device, with that special Apple panache that I've grown to love since I switched 2 years ago (and haven't looked back).

I've been holding out on getting a laptop, hoping an Apple tablet would come along. Hopefully, if true, it will be an Einstein to its doomed predecessor, the Newton.

Tuesday, May 02, 2006

Eric Nagourney writes, "Researchers reported yesterday that when it came to medical treatment, the satisfaction expressed by a group of elderly patients had little correlation with the quality of care they had received based on a review of their medical records."

We all know the type: the guy who works a million hours, puts in overtime, sleeps in his office on weekends, yet still seems to be always drowning. And while yes, he does work a million hours, all anyone really notices is that he's consistantly late in the mornings, or takes a few too many days off for perpetual emergencies. We also know the other guy, the one who is calm, unrushed, in at 9, out by 5, and somehow creates an image that keeps you from asking if all his work is really done, we just assume he's efficient and no one opens his drawers.

A lot of life-- and a lot of doctoring-- is about perception.

Here's a story. Years ago, an acquaintance had an awful accident with a severe vertebral injury resulting in paralysis at the scene. He was transported to a local hospital where a scan showed bone fragments in the spinal canal. The patient was then brought by helicopter to a major academic center where a renowned spinal surgeon (the only one in a multi-state region deemed capable) operated. It was a long recovery period, but the patient was able to return to work within a few months, and was eventually able to resume skiing-- by anyone's measure, his recovery was remarkable. The family, however, walked away with nothing but venom for the surgeon-- apparently he was callous with a cavalier bedside manner. To hear their tales, I had to wonder if, in their minds (though not in the patient's ambulating legs!) all the good he had done wasn't erased, or at least discredited, because of some intangible personality flaw or insensitive word.

The first time I see a new patient, I ask a lot of questions. I start by asking for permission to take notes ("just for the first session, I know it's a little disconcerting to talk to someone who is writing, but it's helpful to me") and I end the 90 minutes of interview with a single final question: "Do you have any questions for me?" I ask. I end this way so the patient won't walk feeling rattled by what might amount to an interrogation. Does it work, does it create a sense that I am approachable, that our efforts need to be teamwork, that perhaps I have some answers? I've no clue (most people come back...) but it leaves me with the perception that I tried!